The Top 5 Reasons to Have a Regenerative Injection

Regenerative injections, also known as orthobiologic injections, include platelet-rich plasma (PRP), amniotic membrane and fluid, alpha-2 macroglobulin and mesenchymal stem cell (MSC)

1)      Cortisone has not gotten the job done- corticosteroid injections are potent anti-inflammatories and can be effective in treating inflammatory conditions, but these have either zero or even a detrimental effect on healing. Most chronic tendon problems are not inflammatory, and thus, cortisone will provide minimal long-term benefit. Not all cases of arthritis are inflammatory either.

2)      You are hoping to avoid surgery or you had surgery and are less than satisfied- we know that certain surgeries produce superior outcomes compared to nonsurgical treatment, particularly in younger and active individuals. Examples include ACL reconstruction after a full ACL tear and shoulder stabilizing procedures after multiple dislocations. However, there are numerous conditions that have equal or superior outcomes with nonsurgical treatment. These include small tears of the rotator cuff, hamstring, patellar and Achilles tendons; plantar fasciitis; degenerative meniscal tears; tennis and golfer’s elbow and mild to moderate osteoarthritis of the knee, hip, shoulder and basal thumb joint. These conditions are ideal candidates for regenerative injections, especially when traditional surgical and nonsurgical treatments are not producing major levels of benefit

3)      Cost- no, insurance does not cover regenerative injections. However, these injections are designed to provide long-term or permanent benefit. The expected goals are months to years of reduction in pain, improvement in function, soft tissue healing and slowing or suspending joint degeneration, i.e., preventing osteoarthritis from getting worse. Thus, these injections have a very good chance of saving you money. These benefits translate into fewer physician’s visits, fewer trips to physical therapy (although we still see the value of PT), fewer medications and potentially, the elimination of the need for an expensive surgery.

4)      You want a game-changing treatment, not one that just treats symptoms- regenerative injections are designed to change the environment of the area injected. Through the introduction of nutrients, growth factors and potentially stem cells, the goal of these injections is to not only make a patient feel and function better, but also to produce a healing response. This can mean tendon or ligament re-growth, cartilage regeneration and/or the reduction of unhealthy inflammation in the area of damage.

5)      The medical literature- although insurance companies would like to paint regenerative injections as “experimental” and thus not pay for them, the truth is that there are now hundreds of studies that demonstrate a clinically significant benefit in the treatment of chronic tendon problems and osteoarthritis with regenerative injections. In fact, hot off the press, a prominent sports medicine journal just posted a detailed review of orthobiologic injections. The authors came to this conclusion:  There was a total of 21 PRP (platelet-rich plasma) studies in the study. All PRP studies showed clinical improvement with PRP therapies in outcomes surveys measuring patient satisfaction, pain, and function…. The one PRP study that had a 2nd look arthroscopy reported increased cartilage regeneration with PRP. All 8 MSC (mesenchymal stem cell) studies with follow-up MRI and all 7 MSC studies with 2nd look arthroscopy showed improvement in cartilage regeneration in terms of coverage, fill of the defect, and/or firmness of the new cartilage.

Translation: patients are very satisfied with their outcomes after receiving these injections, and there is evidence that new cartilage is growing in response to these injections.

In conclusion, regenerative injections are rapidly entering and evolving within the world of orthopedic medicine. At this point, both their present and future look very bright. When considering a regenerative injection, seek the consultation of a medical doctor who has vast experience in researching and performing these procedures.

-Clarke Holmes, M.D. 

The Traveling Doctor's Perspective on Travel to Costa Rica

Why would a physician post a blog on travel on his website? Well, I’ve always had an interest in travel, and that passion has been cultivated especially by my wife’s career choice as a travel adviser. I do spend a sizeable portion of my time outside of the office sharpening my medical skills and knowledge; however, I do not long to be one-dimensional. I would hope that my patients see me as more than a robotic answer to their medical question. I also greatly desire to know my patients well beyond their medical issues. Many of my patients also share my passion for traveling, and I treasure the couple of moments in the patient room when we discuss not only their arthritis, sprain, fracture or tendonitis, but also their past or upcoming domestic or international travels. I can gather their travel tips while also sharing my own. This sharing of information can be one of the highlights of my day. All that being said, here’s some nitty gritty on Costa Rica for those considering a trip to this fantastic country. I’ve been there twice in the past 5 years…once as adult couples and just recently, with my wife and children of 11 and 13 years of age.

WHY GO TO COSTA RICA?: This is a country full of beauty- mountains, volcanoes, animals, flowers and many forms of water. It’s an outdoor paradise for nature-lovers, fisherman, hikers, etc. Plan to be quite active. Of course, you can set your own schedule, but if looking for a low-key place to rest and relax, this is not the place for you. There are other destinations that focus more on R and R. Also, if you do love the outdoors, then your body needs to be prepared for some of the rigors that come with the territory. Those with very symptomatic hip, knee or ankle arthritis, or those fresh off of a lower body injury or surgery, will not find this to be an easy trip. Also, if Costa Rica is on your bucket list, don’t save this one for your retirement years. Many of the activities are not very conducive to older individuals (of course, this is a generalization, not an absolute), and in my travels to CR, I’ve not seen many tourists in their 60s or above.

Costa Rica is a great vacation option for families with active children, ages 6 to 18. Your family gets to experience an international destination, learn some Spanish, not have to travel a tremendous distance from the U.S,. and jet lag is not much of an issue, as CR is the same as the mountain time zone in the U.S. For Nashville, this means Costa Rica is only one hour behind us.

GROUND TRANSPORTATION: If traveling any significant distance from the airport (San Jose or Liberia) or when heading to a tour, I strongly recommend arranging for a private driver. They typically drive mini- to large vans of fairly new and of high quality. The roads are steep, curvy, somewhat narrow and not well-marked. This is not a country I recommend you drive yourself. Also, as a driver, you lose the ability to enjoy the beautiful views that will surround you because your focus is on the road. The drivers also tend to be excellent tour guides as well, providing a wealth of interesting information about the area. Finally, because of the many curves and hills, beware of motion sickness. If you are prone to this, sit towards the front of the vehicle, and for long rides, consider an OTC med such as Dramamine to counteract the motion sickness. My family was on the verge of vomiting a few times, but we survived without any messes!

WHERE TO STAY: If looking for an inland experience, let me endorse two properties. No, I do own stock in either, but I can speak highly of both based on personal experience. The first is the Peace Lodge, located about an hour north of the San Jose airport. This is more of a rustic lodge, developed around an animal sanctuary. The rooms are well-appointed with waterfall themes, especially in the bathrooms which are very unique including waterfall-type shower heads. The room amenities are impressive. The food options are a nice variety of Latin America fare and Americana cuisine. The highlight of this property is the animal sanctuary. Here, you will be up close and personal with toucans, parrots, ducks, monkeys, sloths, snakes, wild cats, poison frogs and butterflies as well as others. Most of our time with the animals was very personalized, getting uninterrupted and one-on-one education from the animal keepers while also experiencing the “high” of actually feeding the sloths, hummingbirds and toucans while holding some impressive non-venomous snakes. There is also a small trout pond where you can reel in a trout with relative ease. While I’ve been to some impressive zoos before in Washington, DC, St. Louis and San Diego, the Peace Lodge blew those away. In addition, all within about a one-mile hike, you can get an up-close look at 7 very powerful and beautiful waterfalls. Finally, the customer service at this property was first-rate.

The next location I recommend is The Springs Resort and Spa. This is located about 3 hours north of the San Jose airport, near the town of La Fortuna and within a great eyeshot of the Arenal Volcano, one of 7 active volcanoes in Costa Rica. The signature of this property is 26 pools, several derived from the mineral water pumped from wells near the volcano area. The pools range in temperatures from 88 to 103. The views from the property are spectacular, especially of the volcano when not covered by clouds, often late in the afternoon. At the base of the property, Club Rio offers numerous outdoor activities including river kayaking and tubing, animal sanctuary tours, horseback riding, ATV tours and rappelling. Off site and within about 30 minutes of the property, we enjoyed a 2-hour guided rainforest hike traveling over many hanging bridges hundreds of feet in the air while seeing monkeys, snakes, lizards, tarantulas, giant grasshoppers, sloths and owls, all in their natural habitat. A chocolate tour was our culinary education on this trip, seeing the process of making chocolate from pod, to bean, to nib to the many varieties of delicious chocolate. You participate in the process and are rewarded with several tastings at the end. Zip lining and coffee tours are two other popular tours for the area, but we did not partake in either this time. The only true drawback to the Springs property is the 2-mile road leading to its entrance. Curves, bumps and pot holes galore define this ride into the property. Once at the Springs, the road can be a deterrent to wanting to journey out from the property on a frequent basis.

A previous journey to the Costa Rica took us to the Pacific coastal area of Jaco, staying at the very nice Los Suenos resort. Golfing and deep-sea fishing were the highlights of this area. An 8-hour journey into the Pacific Ocean yielded some major battles with 75 lb. or greater sailfish, won by the humans. However, this was a “catch and release” outing, and thus, the fish were not significantly harmed, and we had photos and memories to commemorate the experience. Although a coastal area, I would not consider Jaco to be a “beach trip,” as the gulf beaches of Florida are far prettier.

THE COSTA RICAN PEOPLE: Rarely will you find a more friendly and hospitable group of people. This includes the tour guides, the drivers, the restaurant wait staff and all the property employees. These people are all impressively knowledgeable about their country, quoting statistics about their volcanoes, the number of resident animal species, the types of inhabiting flowers and their cuisine. The large majority speak very good English and also enjoy teaching you and your children Spanish along the way. They welcome tips but certainly don’t demand it. The Costa Ricans understand that tourism is a huge part of their economy, and thus, are very hospitable hosts. Fortunately, they don’t have to put up with a “spring break crowd” of college students very often, as travelers to Costa Rica tend to be a bit more calm and sophisticated. No offense to you college students! Also, of note, both American dollars and Costa Rica “colones” are widely accepted by most. Don’t be intimidated by the currency exchange rate: approximately 1 American dollar = 500 Costa Rican colones.

THE FOOD: Obviously, Latin American influence, resembling that of a more traditional Mexican cuisine. Unique options include rice and beans, aka "gallo pinto," a staple on the Costa Rican breakfast table. The fruit is extremely fresh and tasty, including bananas, plantains, papaya, pineapple and guava, among many others. Of course, seafood is a solid option for the area. Parents and those with “tongues of familiarity,” not to worry, American choices such as nachos, quesadillas, burgers and pizza are options at many hotels and resorts.

WHEN TO TRAVEL AND THE WEATHER: The temperature does not vary much in Costa Rica. There are basically two seasons: the rainy and not-so-rainy season. Expect major rainfall from May until December, with one native counting on a break from the rain in July of each year. This break from the rain, however, was not substantiated by other natives. However, traveling to Costa Rica during the rainy season has its advantages. First, the crowds are much smaller. Our 2nd trip in late May almost never felt crowded, and thus, wait times were minimal and our experiences felt much more personalized. Also, prices of the hotels, flights and tours tend to less expensive during the rainy, ”non-peak” season. Finally, after very busy and taxing mornings and relatively non-rainy tours, we welcomed the afternoon rain, giving us permission to catch up on some rest. Alternatively, if you truly desire to travel to CR during the drier season, then late December through March is your best bet. Expect to pay more during this season.

SAFTEY AND MEDICAL ISSUES: As mentioned before, if you desire to partake in hiking, water sports, waterfalls tours and similar activities, you need to be in decent if not relatively good cardiovascular and musculoskeletal condition. Our Fitbits usually read 11,000-15,000 steps by the end of each day. Good condition and slip-resistant shoes are a must. Waterproof clothing is highly recommended. Regarding food and water safety, gastrointestinal issues are always a concern, but at most higher-end restaurants and properties, the water is filtered and food is quite sanitary. I always recommend traveling with a medical bag of OTC meds including pain-relievers, cough and cold meds, motion sickness meds, Pepto-Bismol, an acid blocker, eye drops, antibiotic ointment and minor bandages. In addition, it’s not a bad idea to a have a broad-spectrum antibiotic prescribed by a physician to treat Strept. throat, ear, skin and urinary tract infections. Finally, keep a nice supply of hand sanitizer in your pocket, as you will touch many surfaces contacted by many others and may want to grab a bite to eat spontaneously when not near soap and water. Insect repellent is a must, but anti-malarial medications are not needed in most areas.

In conclusion, Costa Rica is a can’t-miss destination for those who love animals, love the outdoors, appreciate beautiful scenery and desire to experience a new culture without draining the bank account or begging for major jet lag. I wholeheartedly welcome friends and patients to knock on my door if you desire more information on a trip to this fascinating country.

The Guide to Regenerative Injections

Dr. Holmes’ Guide to Regenerative Injections

Regenerative injections are those specifically utilized to promote healing of damaged tissue, reduce or eliminate unhealthy inflammation and slow or halt the progression of soft tissue and joint deterioration. We now use them regularly for tendon problems including tennis elbow, golfer's elbow, the rotator cuff, the high hamstring, patellar and Achilles tendons. We also have seen great success in treating osteoarthritis of the knees, shoulders, hips, thumb and great toe joints. Plantar fasciitis, ligament and muscle tears are great candidates for regenerative injections as well. 

·      Platelet-Rich Plasma Injections

o   Blood obtained from an arm vein is centrifuged for 15-20 minutes, isolating the platelet-rich plasma

o   Platelets are very rich in our natural growth factors (healing agents), and are concentrated 6-10 times their natural concentration

o   Under ultrasound-guidance, the PRP is injected into the damaged tendon, ligament, fascia, joint or muscle

o   Great option for tennis elbow, golfer’s elbow, small rotator cuff tears, small patellar tendon tears, high hamstring tendon tears, Achilles tendon tears, plantar fasciitis, etc.

o   Widely-used also for osteoarthritis of numerous joints

o   PROS: very natural and safe (your blood); used in orthopedics for ~10 years, Dr. Holmes has used for 7 years; numerous medical studies confirm significant benefit; 2-3 areas can be injected at one time; long-term benefit for most patients

o   CONS: these work gradually, over weeks to months; increased pain after the procedure for 2 days to 2 weeks; immobilization required with a splint or boot for some injections

o   UNKNOWNS: length of benefit (can be months to years); number and frequency of required injections. 1-2 injections initially for most soft tissue problems; 2-3 initially for arthritis/joint problems

·      Amniotic Membrane Allograft Injections (brand- AmnioFix)

o   Utilize one of the placental membranes (these cover the fetus during pregnancy) to form a product containing numerous types of growth factors

o   Intended to reduce inflammation, reduce scar tissue formation and enhance healing

o   The membrane undergoes a rigorous purification and sterilization process, and is stored as a dehydrated powder; sterile saline is added to become an injectable solution

o   Great option for plantar fasciitis (#1 use), tennis elbow, golfer’s elbow, small rotator cuff tears, small patellar tendon tears, high hamstring tendon tears and small Achilles tendon partial tears

o   PROS: very safe, with no significant reportable adverse effects; Dr. Holmes has used for 5 years; no rejection, despite not being one’s own tissue; no blood draw required; typically less post-procedure pain than PRP

o   CONS: probably not as effective for joint pain/arthritis; otherwise, same cons as PRP

·      Amniotic Fluid Injections (brand- Catalyst PDA-HAF)

o   Very similar to amniotic membrane injections, but often stored in a frozen form and thawed immediately before injection

o   Contain over 200 different growth factors

o   Great option for soft tissue as well as joint problems such as osteoarthritis

o   PROS: theoretically, a more powerful amniotic product than a dehydrated membrane

o   CONS: more expensive than the dehydrated membrane product

·      Alpha-2-Macroglobulin Injections

o   A natural substance found in our bloodstream

o   Blood drawn from the patient, centrifuged, manually separated and then placed in a separation pump to further isolate and concentrate the A2M

o   45-minute procedure done in one office visit

o   Functions as a “protease inhibitor,” binding the inflammatory proteins that cause the degradation of cartilage in the joint

o   Utilized to reduce pain, inflammation, halt the progression of osteoarthritis and provide “longevity” to the joint

o   PROS: very safe and natural substance; presumed long-term benefit, less post-procedure discomfort than other injections; two to three injection sites can often be chosen with one procedure

o   CONS: newest type of regenerative injection; very few medical studies proving effectiveness thus far, but studies are underway; frequency of injections not known at this point (likely every 6-24 months)

With any of these injections, all forms of ORAL and TOPICAL anti-inflammatories must be stopped for 1 week before and 2 weeks after, as to not interrupt the initial healing cascade initiated by the injections. This includes:

·      Advil/Motrin/ibuprofen

·      Aleve/naproxen

·      Aspirin- any doses above 81 mg

·      Mobic/meloxicam, Celebrex/celecoxib, Voltaren/diclofenac

·      Fish oils/Omega-3 fatty acids

·      Turmeric

·      Oral green tea

·      Glucosamine/chondroitin

·      Arnica

COST: Regenerative injections are rarely ever covered by insurance. Although we closely monitor their coverage status, in the current climate of healthcare and insurance companies reducing their coverage of even typical treatment measures, we do not expect these injections to be covered in the near future.

With rising deductibles, many patients pay out-of-pocket for traditional treatment measures as well. Thus, a regenerative injection may ultimately be a similar out-of-pocket cost to traditional treatments but more clinically effective and cost-effective over the long-term.

A patient should view these injections as an investment into the long-term health of their tendons, fascia, ligaments and joints.

We are here to serve you! 

F. Clarke Holmes, M.D. 

THE ANATOMY OF A LEADER: MY VIEW AS A SIDELINE PHYSICIAN, COACH & PARENT

Over the past 20 years, I’ve served as a coach for youth sports, a team physician working the sidelines & courtside and as a parent of two young athletes. It has been enlightening to observe those athletes who are particularly skilled in their leadership capabilities. I’ve learned that being a leader can take on many forms. There is not a “cookbook” formula, but it is obvious that every type of team needs leaders to succeed. Here are some of the various types of leaders and their attributes.

  • The Encourager - this leader can do so from the field/court or the bench. He (spoken generically, “she” can apply in all situations as well) may be a starter or rarely see playing time. Either way, he’s the one leading the cheers, picking up his teammates when they are down on the ground, congratulating one after a big play or consoling a teammate after a mistake. This type of leader is often an extrovert and tends to be less focused on his own performance.
  • The Leader by Example - this person is often on the quiet side. He doesn’t lead by cheers or many words, but is frequently a workhorse. She is obedient and respectful with her coaches and rarely steps out of line. A coach often asks her to demonstrate various drills during practice. Other players begin to emulate this athlete, and the domino effect has a very positive effect on the team.
  • The Star - this leader is a “gamer.” He wants the ball when the game is on the line. “Ice water in his veins” is a phrase often assigned to this athlete. She inspires her teammates as she does not hesitate to make a big play during a key portion of the game. Even though a excellent player, to effectively be a leader, the “star” must still remain humble and do things on the game or practice field to make his teammates better.

Every team needs leaders. A championship often team has all three types described above. Even if not a winning team, it’s still important to have various type of leaders emerge on each team. These leadership skills often spill into other types of endeavors, perhaps in the academic or business arena. During the formative years, these leadership skills may help your child resist some negative forms of peer pressure.

As a parent or coach, realize that leaders may be born, or they may be made. If you exhibit leadership in your own arena, your children will take notice. Recognize the personality of your child or player and tap into his skill set to develop their particular leadership style. Also, realize that a child or young athlete may be a leader in one field and a follower in another. That is not a weakness, but just a reality. If an athlete gives his best effort in all that he does, then one or more of these leadership styles will often develop as positive bi-product.

Get busy leading!

F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics 

Should My Son Play Tackle Football?

"Should my son play tackle football" is a question I receive on a very frequent basis. Parents are more concerned than ever about the risks that come with playing this collision sport. The first question I ask the parent in return is "Does your son really want to play tackle football?" Football is a rigorous, gladiator-style sport. It often pushes boys towards their limits with regards to commitment, fear, body contact and fitness level. These "pushes" can be a positive thing for your son, but if he is not enthusiastic about playing this sport, then your question has been answered. I strongly discourage participation in football if your son doesn't want to be on that field. 

Here are the reasons your son SHOULD play football:

  • He becomes part of a team, something bigger than himself. Bonding is often very high among football teammates, as they adopt an "in the trenches together" mentality
  • Courage, dedication, loyalty, sportsmanship and confidence are valuable character traits that often develop with a successful football experience
  • Improved fitness levels- football is a sport requiring endurance, speed, quickness and power, with some positions emphasizing more of these traits than others
  • Mentoring- many football coaches become like father-figures to young men, teaching them important life lessons while teaching them football as well

Here are the reasons your son should NOT play football:

  • First and foremost, he doesn't want to play
  • The risk of injury. Here are some important injury-risk considerations:
  1. Size and strength deficits- if your son is physically less developed than many other peers competing in football, then his risk is increased. If the team or league is allowing 140 lb. boys block and tackle 225 lb. boys and vice-versa, then the smaller boy's risk is much greater. In the youth leagues, rules are often in place to reduce this effect. In the high school environment, it is up to the coaches to ensure the safety of the smaller athletes.
  2. Concussions- we could create an entire blog on this subject, but in a nutshell, concussions are common at all levels of football. Contrary to most conditions in medicine, concussion symptoms in younger football players often last longer than those more mature. New evidence is suggesting that the earlier the age one starts having concussions, the greater the risk of long-term problems such as memory deficits and depression, just to name a few. Also, the multiple concussions likely create a cumulative effect, meaning several concussions in a relatively short period of time create more long-term damage than one concussion or a few concussions separated by many years. Simply put, someone playing tackle football for 10 years is much more likely to have more concussions, whether diagnosed or not, than one playing for only 3 years. Improved equipment such as helmets and better tackling techniques may reduce the severity and risk of concussions, but no equipment or rule adjustment can significantly reduce or eliminate concussions. 
  3. Orthopedic Injuries- minor contusions and sprains are part of the game for nearly every player and heal without consequence. However, some fractures and ligament sprains, although appropriately treated, leave football players with long-term pain and dysfunction. For example, despite a successful ACL-reconstruction surgery after an ACL tear, 50% of athletes have knee arthritis within 12 years of the injury. In addition, repetitive microinjury to the back likely leads to an increased risk of disc problems in the cervical and lumbar spine. 

When weighing the risk of injury as it relates to football participation, consider not only the immediate impact of injury, but also the long-term implications of concussions and orthopedic injuries.

If there is an opportunity to play flag football, then I encourage one to play this version for as long as possible. In my opinion, tackle football is a sport that be re-joined or joined for the first time at a later age, perhaps 9th or 10th grade without a major roadblock to success. Years of tackle football does not necessarily guarantee success at higher levels such as high school or college. In fact, beginning tackle football at a young age can lead to burnout or injuries that derail one's ability and desire to continuing playing into middle and high school. 

In conclusion, the decision of whether your son plays tackle football or not must be one thoughtfully considered by and discussed among the athlete and his family members. Risks and benefits for your child should be carefully weighed.

F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics, PLLC